Adult ADHD and academic performance in college

‘Twas the week before finals and all through the dorm, few students were sleeping, since Adderall is the norm …

What is the state of academic performance and achievement in the age of adult ADHD?

Recent media publications feature “neuro-enhancement” sought by college students and stressed professionals through the use of prescribed and non-prescribed medications, particularly stimulants, to guarantee focus, concentration and alertness when needed for studying and work demands.

It’s as easy as bargaining with a roommate for one of their prescribed stimulant pills for $5. Some campus studies suggest as many as 40% of college students self medicate with non-prescribed stimulants during their college years–in certain settings like fraternities and sororities, it can be much higher. Graduate students certainly partake as well, and that includes medical students.

Approximately 15% of students entering university now have been diagnosed (some very cursorily) with Attention Deficit Disorder and the majority of those students are medicated for their illness. This is a significant increase from twenty years ago when I first started working in a university health center. At that time a diagnosis of adult ADHD was extremely controversial and the incidence of ADHD diagnosis for entering freshmen was less than 1%. In 1991 I attended a college health conference where a Harvard Medical School professor flat out called treating adults with stimulants for ADHD a “clear case of malpractice.” Since then, the diagnosis has gone mainstream in the DSM IV and the criteria are likely to be even more liberalized in the upcoming DSM V revision. Some estimates suggest one in seven adults meet criteria for ADHD. That is a lot of inattention and impulsivity out there. That results in a lot of stimulant out there.

Amphetamines are hardly the new drug on the block. In the 50′s and 60′s they were routinely prescribed for “tired housewives” and became the go-to diet pills to suppress appetite and aid weight loss. My paternal grandmother was one of those tired overweight housewives. She kept a large jar on her kitchen table full of multi-colored capsules that she would pop prior to meals. The appealing looking pills appeared very much like a candy jar to her grandchildren. I remember being warned many times that “those are Grandma’s diet pills and you kids can’t take them because they would stunt your growth”. They didn’t seem to do much for Grandma’s weight problem, but they certainly contributed to her moodiness, anxiety and chronic insomnia, a problem that resulted in prescriptions of sedatives to counteract the stimulant effects. She wasn’t alone in her doctor-prescribed addiction to then uncontrolled substances–thousands of patients were treated with similar drugs that worked at cross-purposes, handed over by well meaning physicians who truly believed they were doing their best to prevent suffering in their patients.

Does that sound anything like the well meaning physicians of today who prescribe stimulants based on “evidence based standards” and “best clinical practices”? Currently the diagnosis of ADHD is difficult to standardize and easy to fake for an adult desperate for that extra edge in a competitive world. No imaging studies have become the gold standard and would bankrupt an already overstretched health care system if they did. Indeed, there are many patients who have legitimate need for the benefit that stimulants offer them–I’ve seen the difference it makes in their chaotic lives. But I know there is no way 40% of college students have legitimate need for stimulants–they are self medicating solely for the extra boost they get from speed. This is no different than the pill popping dieters from the 60′s. And I don’t accept 15% of adults warrant prescribed controlled substances for the rest of their lives.

When I see these young adults struggling with insomnia, poor appetite, hypertension, and rapid pulse all thanks to the side effects of their stimulants, it is time to look at other solutions for their learning issues besides amphetamines. Sadly the response from too many doctors is to add on the antianxiety drug, the sleeper, the medical marijuana, the anti-hypertensive. Once again these are well meaning physicians who truly believe they are doing their best to prevent suffering in their patients. It seems we haven’t come far in sixty years. Same overprescribed dependency producing drugs, different diagnostic indications.

It’s time to really take a look at what we physicians are doing in the name of “best clinical practices.” The physical and psychological toll of life long stimulant dependency is clearly understood in street amphetamine addicted patients, what few years they have left because of their snorting and shooting. But we know very little about the ADHD treated individual on routine prescribed amphetamines for thirty, forty, or fifty years or more. In another generation, the health care providers of the future may well shake their heads looking back at our collective ignorance, just as we now shake our heads over the dexedrine- and valium-pushing doctors of fifty years ago.

First, as always, do no harm. It is time to slow down and reduce speed.

Adult ADHD and academic performance in college 13 comments

I wonder how our attitude toward CNS stimulants would change if we thought of them as “performance enhancing agents”(which is, at the end of the day, what they are).

MassachusettsPCP

Thank you for a dose of common sense, citing statistics and alluding to the loosey-goosey DSM criteria. Now I expect waves of responses on how much the stimulant has helped them and changed their lives. During World War II they were handed out to pilots on both sides to increase alertness and lessen pilot fatigue, enabling more sorties. I would point out that the responsiveness to a stimulant – Adderall, Ritalin, cocaine, methamphetamine (they all light up the same areas in the brain) – is not diagnostic for ADHD or ADD. Normal subjects will report that they feel more energy, more focused, and get more things done and on-task.

Why is it that ADHD medications always seem to be the scapegoat in the neuro-enhancement discussion? What about the some 70% (and I think this is lowballing it) of people that seem to fit the criteria for major depressive disorder? And all of the anti-depressant medications being thrown around?? Whether you’re sad that your boyfriend broke up with you and want to fix it, or you’re feeling lazy and need to sit down and finish a paper, how is it any different? Neuro-enhancement is not going anywhere, and it’s far more abundant on medical school campuses than I think anyone wants to believe.

Greg

Neither of the cases you describe would meet criteria for serious mental illness. Crying over your boyfriend breaking up is normal. Feeling lazy and not doing your homework is normal. To really qualify as being ‘abnormal,’ you’d really have to be a couple standard deviations away from a typical behavioral pattern (70% of people fit Major Depression criteria? According to who? Some actual links would be helpful here).

People who use medications outside of pretty extreme illness are using neuro-enhancement. That doesn’t negate the fact that there are some unfortunate individuals who really struggle with these issues day to day, negatively impacting multiple aspects of their lives. For them, these medications can be a godsend. But for others, they’re cheating, frankly.

The question for us primary care docs is what we do instead of prescribe. If I refer a patient for therapy services, they charge $100/hour every week, which my patient can’t afford or insurance wont pay for. So we either do nothing (and likely never see the patient again because we haven’t addressed their problems), or consider available tools. Those who complain about overuse of medications need to advocate for more psychotherapy services or other alternatives. Otherwise, what are YOU doing about the problem?

Megan

My point with those two examples is that there are myriad people on antidepressants for that exact reason. If it’s ok for them to be on a medication like that for something I perceive as neuro-enhancement, then what’s wrong with being on methylphenidate to get you a better grade in a class, or to help you learn more?

It is common knowledge that the percentage of people diagnosed with ADHD is far less than major depressive disorder. I could direct you to my First Aid Step 1 USMLE book if you’d like to look there.

WhatPaleBlueDot

And then there are the ADHD adults who, on stimulants, still suffer from excessive sleeping and have uncontrollable appetites but finally can begin to pay attention in class and actually make it to their exams. Psychiatrists should treat the patient in front of them, not attempt to treat a class of patients.

Massachusetts psychiatrist Emily Deans has an interesting explanation for some of the increase in certain varieties of psychiatric disorder – too much omega-6 in the food supply. Google “Your Brain on Omega 3.

I have adhd and I take a stimulant medication, which helps tremendously. However, relying on medication alone, in my opinion, isn’t the best way to treat adhd. Regular exercise is very important…I can’t stress that enough. I run 4-6 times a week and swim a 1-3 times a week. I also incorporate weight-training into my routine. It it enhances the effects of my medication. I also see a therapist who helps me with issues, as well with practical skills, such as organization, time management, study skills, etc. It has been much easier for me to implement those skills since I’ve been on medication. I’ve tried in the past and it hasn’t worked. Also, eating a healthy diet helps. I’ve found that certain foods effect my energy level and concentration thoughout the day.

If I take my medication, exercise, eat a healthy diet, and implement the tools I’ve learned from my therapist I don’t have problems with my adhd that often. I do have adhd days every now and then, but compared to my life before, I’m very pleased.

Well said.The “epidemic” of ADHD is a co-dependency between doctors who want to help and patients who want a certain outcome. The willingness of patients to fit a medical model and the willingness of doctors to accept normal life as an illness will be looked back on in horror.

Carl Sagan

Speaking as an uninformed layman, I fail to see the harm in the occasional use of ADHD medications. I understand the obvious consequences of addiction but it seems that addicts are the extreme minority of users. What about the majority of college users who take a pill a week or even only twice a year before finals?